Public Health à la carte

New guidance on breast screening will stress the importance of individual choice in the context of access to (and understanding of) scientific information. It is now official NHS policy to draw attention to the fact that population-based breast cancer screening can lead to both over-diagnosis and over-treatment – both potential downsides from an individual point of view. From now on, women are to be encouraged to find out the facts, and then make a personal choice about whether or not to take part.

On the face of it, that seems like a pretty good place to be. But when you scratch the surface of this very reasonable sounding proposition, some serious issues about the background politics of Public Health are revealed. Although couched in the laudable language of freedom of choice, the new developments in breast screening represent the essentially illogical idea of Public Health à la carte. And if you travel too far up that route, your service actually ceases to qualify as Public Health.

A screening service relies on a multitude of individual actions occurring in the context of a “programme”. Successful screening needs millions of citizens to decide, individually, to attend an examination or test of some kind. Even though they, personally, will not have experienced symptoms, they understand that hidden cases of the illness are scattered throughout the population. Realising that finding these hidden cases needs everybody to attend, they behave en masse, creating the possibility that an entire population can be treated meaningfully as a unit of medical intervention. This is, in a nutshell, a fundamental principle of Public Health.

Until now the NHS breast screening programme has sent individual women over a certain age a personal invitation to take part. The invitation represents a framework of clear ‘official’ advice based on an expert analysis of scientific evidence. Women are essentially being asked – “please, take part”. The NHS backs this up by making access to screening easy – clinics and health centres being augmented with mobile caravans in public places.

What’s interesting about the recent breast screening developments is that they represent a shift in emphasis in some of these elements. In some respects, the new guidance makes population breast screening more like flu vaccination.

In the case of flu vaccination, a selective entitlement to the intervention is based on the risk profile of an individual patient. For those not falling within the officially delimited risk categories, the injection can be purchased from shops and private companies. In systems of this kind, GP’s are often paid a bonus to encourage them to actively “recruit” eligible patients to the programme by invitation or advertising.

For people in one of the recognised risk groups, the message being given is that there is clear “official” advice based on an expert analysis of scientific evidence. They are being told by the NHS – “we genuinely think it’s a good idea for you, personally, to have his injection”. The message to people outside the recognised risk groups is that they should examine the scientific evidence themselves, map the analysis onto their own lives and then make a personal judgement as to whether it is worth buying the injection on the open market.

Plainly breast cancer screening and flu vaccination are not the same thing. The former is about case finding and early treatment. The latter is about inoculation and prevention. However, as pieces of policy, they both share some very important attributes as far as the overarching philosophy of Public Health is concerned.

They are both based on the technological possibility of reducing the burden of illness in the community in general by dealing with the population as a unit. And in both cases the overall goal is not simply to reduce the overall amount of human suffering in the population. It is also to reduce the amount of public resources which need to be spent on dealing with illness in the medium and long term. By spending money on a campaign now we save money in the future because not as many people become seriously ill. It’s one of the reasons for having Public Health in the first place.

So what, concretely, are the real differences between the old approach to breast screening and the new advice? Crucially it is about the relocation and recasting of scientific evidence and what that evidence means in terms of real people’s decisions.

In the new guidance, individual women are being told to find out the scientific evidence, analyse it, and then exercise an individual choice. Statistical and epidemiological specialists in public institutions like NICE and academic networks such as the Cochrane Collaboration are either being sidelined by politicians or they are losing the will to give the populace a clear steer one way or the other. They will not from now on be providing policymakers and individuals with clear recommendations. Rather they will be saying “here is the data – make up your own mind”. As a taxpayer I’m tempted to ask – why have a dog and bark yourself?

Someone in British public life once famously said that there is no such thing as society, there are simply individuals and families. Whoever is re-making breast screening policy seems to be belatedly catching up with this idea. And in doing so they are losing touch with an important reality – that health is not just an individual experience. It’s a social and public good.

5 comments

Dear colleagues. As an admirer of your website I have to disagree with what you say here. There is no herd immunity benefit from this screening as breast cancer is not infectious. Screening cannot prevent breast cancer. It does seem that some women who would have died of breast cancer will not if they are screened but 4 times as many will have expensive and stressful treatment for cancers that would not have killed them. So this screening really does need to be a matter of choice.

Thanks for the comment – my piece isn’t meant to be either pro or anti any particular screening programme. As I understand it, there is quite a lot of evidence to suggest that population based breast screening might be a seriously bad idea. The point I was trying to make is that you either have Public Health or you don’t. The whole point is that people join together to do things collectively, for collective goals – if there is a good reason. My beef is with the introduction of individual risk balancing and “choice”. It’s daft and inappropriate. The new breast screening advice is based on the scientists and Public Health officials seemingly avoiding their responsibilities. They want the pay cheques, but don’t want to do their job. In any Public Health campaign the population deserve a clear steer one way or the other. Breast screening is either a good policy or it isn’t. It should not officially be a matter of individual risk taking – Public Health doesn’t really work “a la carte”. I am suggesting that population approaches to health need to go along with clear publicly stated (and evidence based?) policy. The new advice for breast screening is basically a mealy-mouthed cop out by the “experts”. They are saying “thanks for the large salaries – but we’re not putting our professional reputations on the line, so make up your own mind”. Where we are now is the worst of all worlds, therefore.

Here is what Cochrane Centre concluded in 2008, very clear summary of evidence. “for every 2000 women invited for screening throughout 10 years, one will have her life prolonged and 10 healthy women, who would not have been diagnosed if there had not been screening, will be treated unnecessarily.”

I have to say, I agree with Mel here. I don’t see the parallels between breast screening and flu vaccination. They are not, as I understand it, “both based on the technological possibility of reducing the burden of illness in the community in general by dealing with the population as a unit”: while with flu there is the benefit of herd immunity; but with breast screening, the overwhelming majority of both the benefits and the risks accrue at the individual level (notwithstanding the socialisation of treatment costs via the NHS and the knowledge benefits derived from analysing larger audit databases and registries).

I don’t see this as a derogation of duty by the experts, but rather a recognition of the importance of individual autonomy in a field where the benefits and risks will accrue differentially to different individuals. This is partly about variance in risk factors (age, family history, health-related behaviour etc.)–and here there is clearly a place for expert advice to inform individual choices–but it is also about an autonomous individual’s attitude to risk–and that is a personal disposition, that no amount of epidemiological expertise can assist with. As Mel points out, expert advice is available, and (for better or worse) normative ‘nudges’ towards uptake are not going to disappear, leaving the patient with no indications as to what they might or ‘should’ do. But it is perfectly possible for individuals with the same risk profile coming to reasoned decisions to do different things, based on their own knowledge, social position, attitude to risk etc. If this is public health a la carte, the opposite (and for me, greater risk) is one-size-fits-all imposition.

Graham Martin’s description of “Public Health a la Carte” is sooooo much better than mine! Thank god Bazalgette didn’t have to contend with a world in which it was “perfectly possible for individuals with the same risk profile coming to reasoned decisions to do different things, based on their own knowledge, social position, attitude to risk etc.” – Some po-mo individualists might not have hitched their bogs up to the sewers and where would we have been then! 🙂
Seriously, though,- thanks Mel and Graham for the thoughtful replies/posts. My initial thinking about “PH a la carte” is definitely a bit on the fuzzy side, and your comments have given me lots to think about. (like am I hankering after a Victorian golden era that no sane person would recognise!! – or even worse, a Stalinist golden era which no sane person would want!!)